RPM Plus: What We Do: AMR - Improving the Use of Medicines through a DTC in Kenya

Sital Shah was an active participant in the international Drugs and Therapeutics Committee/Training of Trainers (DTC-TOT) course in Malaysia held November-December 2005.

One of the activities she was able to do immediately upon her return to Kenya was to apply prescribing indicators to almost 500 outpatients seen every day in her hospital's outpatient primary healthcare clinic.

Injections are overused in many developing countries because of patient demand and the perception that more injections will have additional benefits for the patient. However, they should be given only when necessary because of the high financial and administrative costs that are incurred when too many are taken, the risk of transmitting infections, and the potential for adverse drug reactions.

Sital said that everyone in her hospital knew that injection usage was high. But evidence in numbers was lacking and the use of the prescribing indicators was the first step. The contributing factors for the high number of injections are:

Patients asking for them
Heavy use by private physicians who are not hospital-based
Lack of standard treatment guidelines (STGs)

The baseline study was performed in January 2006 and the study's sample size was 300 prescriptions, of which 50 prescriptions were randomly selected every day for six days. The results are presented in the table below.

WHO/INRUD Prescribing Indicators	January 2006	May 2006
Average number of medicines per prescription	3.4	2.4
Generic prescribing	40%	43%
Prescriptions with antibiotics	40%	37%
Prescriptions with injections	20%	10%

Based on Sital's study results, which were reviewed and agreed upon by the primary healthcare clinic head, her DTC made a collective decision to remove certain injections from the formulary. These were paracetamol, aspirin, Buscopan^®, and Zantac^®. A similar study using the same sample size was performed in May 2006 and it can be seen that outpatient prescriptions with injections were reduced to 10 percent.

Sital's DTC used studies on IM drug availability to educate prescribers about problems of paracetamol injection and now use of IM paracetamol has been officially discontinued. The DTC support team from MSH/RPM Plus assisted Sital with criteria for appropriate use of aspirin, Buscopan, and Zantac injections.

Sital mentioned that the evidence-based information provided to her by MSH/RPM Plus was very helpful in convincing her DTC to remove the injections from the formulary. Additionally, a new physician who practiced for some time in the United Stated understood all the principles and supported her recommendations. He spoke to the hospital's doctors about the appropriate use of injectables. In the future, if these injectables are needed, justification has to be provided by the requesting physicians.

Establishment of an Antimicrobial Subcommittee

Sital Shah in a discussion with her DTC antimicrobial subcommittee members

Another achievement for Sital is the establishment of an antimicrobial subcommittee to monitor usage of antibiotics in critical care units. The subcommittee membership is multidisciplinary and consists of a clinical pharmacist, a microbiologist, an ICU nurse, an ICU physician, and Sital.

Sital was able to convince her DTC to establish this antimicrobial subcommittee after she performed the ABC analysis on antibiotic use that she learned from the DTC-TOT course in Malaysia. She also made a summary presentation about the ideal components of a DTC which helped her make the case for establishing an antimicrobial subcommittee.

The terms of reference and functions for the antimicrobial subcommittee were established. Sital also shared a copy of the minutes of their first meeting.

The subcommittee developed an order sheet to rationalize the use of antibiotics. It also established a policy that restricted antibiotics must be authorized by the microbiologist before being dispensed by the pharmacy. In addition, a drug use evaluation (DUE) for meropenem is being performed with the goal of providing conclusive data for intervention.

Sital's story clearly suggests that improvement in rational use of drugs can happen as a result of using evidence-based data and strategy. Sital took great pride in being able to use what she learned in the International DTC-TOT course and apply the lessons and techniques in her everyday work. She also took satisfaction in the fact that improvement of her work was contributing to the promotion of rational drug use. Currently, Sital's DTC is in the process of reviewing the use of diclofenac and certain antibiotic injections to ensure that they are appropriately used.

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